THE ROLE OF THORACOTOMY IN THE DIFFERENTIAL DIAGNOSIS OF PLEURAL EFFUSION

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Abstract
Established value of thoracotomy in differentiating tuberculous from nontuberculous pleural effusions was made by review of records and pathological material on 63 patients receiving open thoracotomy in the diagnosis or treatment of pleural disease. Of these patients, 38 had a final diagnosis of tuberculous pleuritis and 25 were nontuberculous. A positive tuberculin test was present in all tuberculosis cases, although most of the nontuberculous cases also had positive tuberculins. Bacteriological findings and pleural fluid findings are not consistent enough to permit a differential diagnosis. Full thoractomy is felt to give maximal visualization and an opportunity to examine the entire thorax. In 9 of 25 nontuberculous cases significant pathologic findings other than pleural were discovered at thoractomy, and in 10 of 38 tuberculosis cases significant nonpleural tuberculosis, unsuspected clinically or by X-ray, was discovered at thoractomy. In 3 tuberculosis cases the pleura was nonspecific but definite subpleural tuberculous nodules were resected at thoracotomy, providing the correct diagnosis. Morphologic findings at thoracotomy differentiate tuberculous from nontuberculous pleuritis with an accuracy probably greater than 92%. The possibilities of bacteriological confirmation on the resected specimen vary inversely with the duration of preoperative chemotherapy. Specific chemotherapy regimens do not seem to be important in determining whether or not positive bacteriology will be obtained on the resected specimens. Connotations of the present study are discussed and a controlled protocol study for the differential diagnosis of pleural effusion comparing a value of limited biopsy versus full thoracotomy is outlined. It is concluded that open thoracotomy can be used with a high degree of accuracy in differentiating tuberculous from nontuberculous effusions in cases where such differentiation is clinically indicated.

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